Temple Grandin

"I believe that doing practical things can make the world a better place."

I first learned about Temple Grandin through NPR's This I Believe series. Now the outstanding HBO film Temple Grandin has brought her experiences as a high-functioning autistic person, her revolutionary creative and scientific work in the humane treatment of animals, and most wondrously, her mind, to life.

Claire Danes is phenomenal in the title role - that, we could have expected, though watching her become Temple Grandin physically, intellectually, and emotionally before our eyes is astonishing even beyond those expectations. But equally impressive is the way in which this breath-taking film captures the lived experience of Grandin's unusual mind. My husband and I were stunned and deeply moved as we watched it last night.

The film Temple Grandin manages to use cinematography to manifest intellect. Sometimes the camera cuts away temporarily to the very concrete images that come to Grandin's mind when people utter words like "miracle" or "animal husbandry," giving viewers an idea of the way she really does think in pictures. Camera angles and direction are used to help us understand her perceptions of the world around her, the discomfort of certain stimuli such as the clatter of eating utensils, the brilliant, intuitive insights she had about the mathematical relations of objects and their mechanics. Small moments convey a lifetime of struggle to understand humanity - her own and others', as well as the inhumanity she witnessed. As she says in the film, "Nature is cruel, but we don't have to be."

Since I learned about her, Temple Grandin has been an inspiration to me. I am not autistic, but I have had occasion to seek neuropsychological testing for certain cognitive challenges - and it was almost a relief to be told I had outright failed a couple of measures, so I could say to the people who had seen me get straight A's for much of my life and couldn't believe I might have a problem, "See? The world isn't always simple for me! There's a reason I get stressed out!" I grew out of my childhood echolalia and sensory integration issues (for the most part), but I often still feel like a mind in cognito, an individual with subtle issues and challenges passing for "normal" by being capable of achieving things.

Nonsense, some people might be tempted to say; you graduated from medical school - how can you talk about cognitive problems? To them I say, do you have any idea how many people struggle through med school, and succeed and become great physicians, with learning disabilities, mood disorders, ADHD, and other perhaps undefineable brain issues? Don't you realize how ways of thinking, perceiving, and processing just can't be so easily boxed into constructed categories?

I found myself able to relate so well with the perceptions of the world brought to life in the film and in Grandin's own words - especially the "thinking in pictures" (though how I wish I had her photographic memory!), discomfort and stress with certain kinds of sound and touch, and anxiety (and seeming "lost") in new environments or with the way people gIve directions or explanations. Grandin's story reminds me that none of us is alone in our struggle to relate to the world and each other; that there are those like her who have suffered much more and then achieved much more; that we all occupy an intellectual spectrum that connects us much more than it divides us. In the end, it was a story of hope - subversive, uplifting, challenging, and timely.

___________________________________________________________

Just out of curiosity, I took the non-diagnostic Autism-Spectrum Quotient found here. "Average" score was 16, likely to fall on autism spectrum was 32. ("Eighty percent of those diagnosed with autism or a related disorder scored 32 or higher. The test is not a means for making a diagnosis, however, and many who score above 32 and even meet the diagnostic criteria for mild autism or Asperger's report no difficulty functioning in their daily lives.")

I scored a 30, probably kept out of the spectrum by a "normal" empathic ability, ability to process noverbal social cues, and perhaps my love of fiction. When my husband looked at the test with me and gave the answers he thought I should have given, I scored even higher, 31. Good thing he makes such a good "hug machine." :)

The Cleaning Guy

Sometimes when Pablo pushed the enormous, wheeled, plastic trash receptacle down the hallway, he would see faces among the bags of waste. Faces from his past, from the once-war-torn home he'd left behind, and from his more recent life in this new world, where after twenty years he still couldn't speak, couldn't understand what people were saying. The trash bin was his scrying glass, the rhythm of its wheels coaxing memories forward that he didn't want but couldn't hide from himself.

He lived alone among others like him, others who spoke what he spoke and ate what he ate. It took him a long time to commute here at night to collect the trash and clean the floors in this place where suffering and healing touched at the edges. He had a wife who had found another man, and a six-year-old son he was never allowed to see. His back ached and his false teeth were loose, so even if he did find someone who spoke and understood Spanish, they kept rattling around in his mouth when he talked to them. His life was one of silence, loneliness, and prayer. His faith was everything he had, everything that mattered.

There was a doctor where he worked at night who sometimes spent the night there on duty. She looked young - just a kid, though she must have been older than she looked. She always smiled and said, "Hi, Pablo" whenever she saw him. She would say hi to Anita too, who cleaned the women's locker room, and Campbell, another guy on the housekeeping staff who had recently quit the night shift.

One night, when there were no emergencies in the operating room and the women in labor had all given birth, this doctor was in an office along the corridor where Pablo did most of his work. She saw him walking by, pushing the giant trash can along, and she ran to the doorway. "Pablo! Pablo, may I ask - where are you from?" And Pablo realized he understood what she was saying, though she was speaking fast. The doctor spoke Spanish.

"El Salvador," he replied.

All of a sudden the doctor was excited. She threw her hands up toward heaven and said she needed help with something, some music project or something, and wanted to learn about his country.

"Were you there during the war?"

Her Spanish was a little rusty, and sometimes she had to take a moment to find a way to express herself, so more often than not she would just blurt out such questions, questions which should have been jarring but which Pablo found strangely normal. Tell me about it, she was saying. Tell me what you saw. I want to know. I need your help.

They talked for a long time. Anita came and emptied the office wastebaskets while they were talking. Across the hallway, the recovery room nurses were turning monitors off and packing up their last patient for transport. Bits of story came rushing out of Pablo, and the faster they came, the more there were. He couldn't understand how something could feel both painful and wonderful: to remember, but also to be heard.

"It was even worse, then, than what the movies about it show," the doctor said. "How on earth did you survive?"

"The mercy of God," Pablo said.

But what of those who had perished? the doctor was thinking. Were they meant to know no mercy, to be tortured and treated as if they were more worthless than the dust and excrement on the road, and then left by the road to die?

What a topsy-turvy thing, this night. The war had taught him that people were worthless (though his faith proclaimed otherwise), and he knew he was nothing, nobody, but then here this doctor was hanging on every word as if nothing were worth more to her at that moment. What was it the young people said? W - T - F, or something like that?

Then somehow they were no longer talking about the war. He talked about this life, how he rediscovered his faith, how it sustained him in his solitude now. And as he talked, his heart opened more and more, and he could feel something changing, as if a beam of light were shining into the chambers of his heart and illuminating them from within.

"God has a purpose for you," Pablo said to the doctor. "Find it." And he began to pray over her. The words, like his story, came spilling out almost involuntarily. It was almost as if he were not the one praying, but rather some other voice, an energy like a wind blowing him along, blowing through him. The gust intensified, carried his words toward her; he felt another power at work, something from beyond the two of them, and he trusted it.

When he finished his prayer, he opened his eyes and looked at the doctor. She had her eyes closed and her hands folded in her lap, her head bowed as if receiving a blessing as Pablo stood over her. Then she opened her eyes.

"I don't know why we had this conversation," he said to her, with tears in his eyes. "But I thank you." Then he went back out of the office and continued pushing the bin of trash down the hall.

Best Anesthesia-Related Blog Post in Recent Memory

Please check out Mommydoctor's post Anesthesia Residency By the Numbers, recently re-posted on Mothers in Medicine. It's funny, it's TRUE, and it's just plain great.

Her blog is fantastic, as are some of her older writings, where the aforementioned post dwells.

Timber

I was doing a spinal for a patient seated in front of me on an operating table. In front of her, facing me, her nurse was holding her steady; behind me, a tall, young nursing student stood observing.

Three minutes passed between the time I prepped the skin with sterile solution and the moment I injected anesthetic into my patient's spinal canal. "You're all done," I said cheerfully and withdrew needle and syringe out of her back in one motion. "We'll have you lie down in just a second."

All of a sudden the nurse's eyes widened and she said in a firm voice, "Sit down. Sit down right now. Right now, sit down, RIGHT NOW." She was gazing past me. I put my hands on the patient's shoulders and turned my head to glance over my shoulder in time to see the nursing student teetering on her feet trying to make her way to the nearest wall. With me now in charge of holding our patient, the nurse rushed around the operating table toward the student and arrived just in time to support her crumpling body before it hit the floor.

Vasovagal syncope is a very real concern and not uncommon in bystanders observing procedures that involve the insertion of sharp objects into patients. I once saw a tall adolescent male fall back unconscious because of an I.V. In a case that would fill any conscientious anesthesiologist with dread, the husband of a woman who was getting an epidural for labor fell, hit his head, and DIED of an intracranial hemorrhage. This page has an interesting comparison of legal cases brought against hospitals on behalf of people who have fainted while observing medical procedures.

I don't think it's fair to assign blame for fainting. People can't help their physiologic reactions, which can sometimes be unpredictable. Different people have different triggers. Some can't stand needles; others, blood or fractures or internal organs; my Achilles heel is the drainage of pus. Even just thinking about that can provoke that unpleasant, pre-vomit tickle in my throat. Needles commonly seem to be problematic for the toughest-looking individuals, so I try not to judge by appearances. But it can be tricky, this business of trying to be mindful of observers' needs when all we really want to do is put 100% of our focus on our patients.

I hope that student is okay.

Satisfaction

I have been neglecting this blog lately. Every time I stop by without writing something I feel a little guilty.

I haven't felt much like writing about medicine, or music, or my family, or food, or even books - all the things that I've loved writing about in the past. Yet there's been no dearth of activity in those arenas. My job is busy as ever. My music projects and those of my children occupy a lot of our energy and free time. I've recently read a terrific book (The 19th Wife by David Ebershoff). I'm still enjoying a rich culinary and family life. What's wrong with me?

I don't think it's depression rearing it's ugly head, because I'm feeling pretty darn happy, my marriage is great, I'm eating and sleeping just fine, and life is good.

There is one nagging question on the depression screens, though, that stands out in my mind - the one about loss of pleasure in activities in which one used to take pleasure. That one's bothering me. I still take pleasure in reading, writing, music, dance, family game night, great meals with great company, and all that. But I'm in a personal slump over my work.

It's more than just the difficulty of going back to work after a long break. Vacation was great, going back to work was hard, but usually after the initial plunge I get back into a rhythm and it's as if I never left. This time, though, the water still feels as icy now as on the first day back. I'm experiencing an inability to enjoy the aspects of my work that have, to date, made a life in medicine worthwhile for me.

In the past I've acknowledged that an anesthesiologist can't be in it for personal glory, ease of work, external affirmation, and the like. More often than not we get the opposite - complaints from people who don't like our decisions, lack of respect from people too ignorant about or indifferent to our duties and skills, hard decisions, tough clinical challenges, frustrating procedures, tiring days and nights, and little appreciation. The work, therefore, has to be its own reward, and for the most part, it has been. It's wonderful to relieve suffering, keep people safe, console them when they're afraid, be there for them when they need help and competence. Those have been the things that have given me satisfaction.

Since my return I've taken care of a couple of people with dangerous heart problems and seen them safely through surgery. I've helped women in labor get rid of their pain and be able to enjoy bringing their babies into the world. I've taken care of frightened children and tired elderly people. I've rescued epidurals and airways that others have had difficulty with. One airway, in fact, involved a patient perilously close to the edge whom two emergency physicians and one surgeon had tried to intubate without success. They were all at the bedside along with a couple of nurses and a couple of respiratory therapists when they handed me the equipment and let me do my thing. It turned out to be a classic "anesthesia save" of the type of difficult airway situation I've described so much already - one of my favorite ways of giving help with the work I do.

Even with fairly routine procedures we're not always entirely unappreciated. One of the psychiatrists in charge of ECTs, according to the nurses, has expressed how much she prefers the days when I'm on ECT duty, because of the tone I set, the atmosphere of calm in the room when I'm there, and the high level of care her patients receive. When I work with her in that setting, I do feel I've done good work, and that old sense of satisfaction returns.

You'd think with all this good work done, I'd be feeling pretty good about my job. The "Three Signs of a Miserable Job" as delineated by best-selling author Patrick Lencioni - anonymity, irrelevance, and the inability to asses one's own contribution to others or success - shouldn't be pertinent to my situation. But often I do feel like a replaceable cog in a big, impersonal machine, and I know this is true for many, perhaps most, workers. That's life, right? And we should just shut up and be grateful we have jobs? Fair enough.

I'll admit I'm sensitive. My satisfaction is often diminished by the sheer unpleasantness of the atmosphere in which I'm doing the work, or by workplace frustrations and politics, and amplified if the work occurs in a supportive or positive environment. This, of course, points once again to the recurring realization that I really need to have a thicker skin, that I shouldn't let external affirmation or its absence affect how I feel about myself or the work I do, and that I need to rely on my own inner sense of commitment, honor, and success to find satisfaction. I know all this. I know. I'm responsible for my own happiness. I know. I've told myself this over and over since I began in medicine.

But you know, sometimes, don't you just feel like saying, "Eh, screw it, I'm moving to Boracay?"

News From Haiti

Photo: Bas-Ravine in northern part of Cap-Haitien, © Rémi Kaupp, CC-BY-SA,Wikimedia Commons

Please check out Paul Levy's full post From Haiti: "Life Really Just Goes On," in which he posts a portion of the field diary of Dr. R. Malcolm Smith, Chief of Orthopaedic Trauma at Massachusetts General Hospital.

An excerpt ("rhabdo" is short for rhabdomyolysis, a dangerous condition that can develop after severe crush injuries):

"Discovered the only blood tests we can do is a crit and cross match. No facilities to do electrolytes. Problem with rhabdo patients so watching urine colour and volume pushing fluid and diagnosing acidosis clinically. No iv bicarb so took advice and sent someone to buy baking soda to give orally not sure. Can someone ask our renal guys about renal protection in this situation?

"Done 16 cases so far through 1 room in 3 days operating and 1 more to do tonight...Have about 60 waiting most with wounds and open fx.

"Had to operate for a short time with head lights when power cut this evening. Thank you Mary and LL Bean...C section just happened, our anaesthetist helped, baby looks fine. Life really just goes on. "

Haiti

Click photo above or here to make a donation. To create a similar post on your blog, click here. To see updates about the work being done by MSF/Doctors Without Borders, click here.